Yesterday, the Department of Health and Human Services (HHS) finalized provisions in the Affordable Care Act ensuring that health plans offered in the individual and
small group markets, both inside and outside of health insurance marketplaces (also called "exchanges") offer a core package of items and services, known as essential health benefits (EHB).
Beginning in 2014, all nongrandfathered health insurance coverage in the individual and small group markets, Medicaid benchmark and benchmark-equivalent plans, and basic health programs (if applicable) will cover EHB, which include items and services in 10 statutory benefit categories, including rehabilitation and habilitation services and devices. These benefits will be equal in scope to a typical employer health plan.
The final rule defines EHB based on a state-specific benchmark plan. States can select a benchmark plan from among several options, including the largest small group private health insurance plan by enrollment in the state. The final rule provides that all plans subject to EHB offer benefits substantially equal to the benefits offered by the benchmark plan.
The final rule also includes standards to protect consumers against discrimination and ensure that benchmark plans offer a full array of EHB benefits and services.
Substitution within EHB categories is still permissible to provide greater choice to consumers and promote plan innovation through coverage and design options. The requirement that any substitution must be actuarially equivalent is retained in the final rule. It is up to each state to set criteria for substitution.
HHS does not provide a federal definition of habilitative services in this final rule. If habilitative services are not yetcovered by the EHB-benchmark plan, then states have the first opportunity to determine which habilitative benefits must be covered by their benchmark plan. States may choose either the
definition used by the National Association of Insurance Commissioners or Medicaid. If states have not chosen to define habilitative benefits, the health plan issuers' will
determine the benefit. This is a transitional policy, and HHS intends to monitor available data regarding coverage of habilitative services.
HHS also finalizes actuarial values (AVs), also called "metal levels," to assist consumers in comparing and selecting health plans by allowing a potential enrollee to compare the relative payment generosity of available plans. Nongrandfathered health insurance plans must meet 1 of 4 specific AVs: 60% for a bronze plan, 70% for a silver plan, 80% for a gold plan, and 90% for a platinum plan.
APTA was highly involved in the processes that determined how EHBs should be defined. The association submitted comments to HHS in response to a December 2011 guidance bulletin, the Center for Consumer Information and Insurance Oversight's January 2012 bulletin, and the Institute of Medicine's report Essential Health Benefits: Balancing Coverage and Cost. APTA also took part in all public stakeholder meetings. Throughout the development of EHB, APTA urged HHS' secretary not to overly define the categories so that practitioners have the flexibility to provide both the type and frequency of care that is medically necessary for each individual.
APTA will post a comprehensive summary on the final rule shortly.
PT, DPT, PhD, FAPTA, a clinician and educator for 38 years who held numerous
national and state positions within APTA, died February 17. She had acute pneumonia that activated
interstitial lung disease, a condition she was diagnosed with 7 years ago.
Melzer served on
APTA's Board of Directors as director (1987-1992) and secretary (1992-1995), and on
the Executive Committee (1991-1995). She also was a member of the Nominating
Committee (2003-2006), serving as chair for 1 year (2005-2006). Most recently,
she was member of APTA's House of Delegates (2007-present).
A member of the
Education Section since 1976, Melzer served in numerous roles, including vice
president (2000-2004). She was a coeditor of A Normative Model of Physical Therapist Professional Education, Version 2000. In 2003, Melzer was named
a Catherine Worthingham Fellow, APTA's highest honor.
She also held
many positions at the state level. She served as president of the Texas Chapter
(1983-1984) and as chief delegate (2000-2003). She was a member of a variety of
chapter committees, including conference planning, bylaws, and educational
was professor at Texas State University and director of clinical education. She
represented the School of Health Professions on the Faculty Senate and was a
multiple winner of the Texas State University Presidential Award for
the incredible span of her service and lengthy list of accomplishments, she has
impacted the profession in ways no words can accurately capture," Eric
Robertson, PT, DPT, OCS, FAAOMPT, wrote in a tribute to Melzer.
President Paul A. Rockar Jr, PT, DPT, MS, recently participated in Healthy,
Wealthy, and Smart, an internet radio show hosted by Karen Litzy, PT, MS, to
discuss the future of the physical therapy profession. During the 1-hour
segment, Rockar answered questions and spoke on a variety of topics affecting
our profession, including health care reform and how it will affect physical
therapy, the "triple aim" of health care and how physical therapy
fits into the overall health care system, and issues related to direct access,
among others. The show, which originally aired on Monday, February 18, can be
heard anytime online at http://www.talkingalternative.com/monday-shows/healthy-wealthy-smart.
patients with radiculopathy due to cervical disc disease, anterior cervical
decompression and fusion (ACDF) followed by physical therapy did not result in
additional improvements in neck active range of motion, neck muscle endurance,
or hand-related function compared with a structured physical therapy program
alone, say authors of an article published this
month in Spine. They suggest that a
structured physical therapy program should precede a decision for ACDF
intervention in patients with radiculopathy to reduce the need for surgery.
this prospective randomized study, 63 patients with radiculopathy and magnetic
resonance imaging-verified nerve root compression received either ACDF in
combination with physical therapy or physical therapy alone. Outcomes,
including active range of neck motion, neck muscle endurance, and hand-related
functioning, were measured in 49 of these patients by an independent examiner
before treatment and at 3-, 6-, 12-, and 24-month follow-ups.
were no significant differences between the 2 treatment alternatives in any of
the measurements performed. Both groups showed improvements over time in neck
muscle endurance, manual dexterity, and right-handgrip strength.
Bruce Braley (D-IA) recently reintroduced legislation to ensure that
communities have access to a wide array of comprehensive health care services,
including physical therapy. HR 702 amends the Public Health Service Act to
establish a Frontline Providers Loan Repayment Program that would allow states
the flexibility to bring health care providers to specific areas of need and
incentivizes the transition to an interdisciplinary approach to health care.
bill was referred to the House Committee on Energy and Commerce on February
About a quarter of recreational
skiers who tear their anterior cruciate ligament (ACL) on the slopes can be
successfully treated without surgery, according researchers at Hospital for Special Surgery in New York City. Their article
appears online ahead of print in the journal Knee Surgery, Sports
The study found that at 6 to 12
weeks post-ACL tear, results from 2 tests that involve only the physical
manipulation of a knee can identify skiers with a torn ACL who will recover
The researchers examined records of
patients treated between 2003 and 2008 to identify recreational alpine skiers
who were seen within 6 weeks of a first-time ACL tear. To be included, skiers
had to have ACL rupture documented on an MRI after the injury and a minimum of
2 years follow-up. Patients were excluded if they had injured ligaments in both
knees. They identified 63 acute, first-time skiing ACL tears; 29 of these
patients did not undergo an ACL operation.
The researchers then separated the
29 patients into 2 groups, those that had low-grade Lachman scores and negative
pivot shift tests, indicating a potentially healed ACL, and those that had
Lachman scores of 2+ and a positive pivot shift test indicating a damaged ACL.
Six to 12 weeks after injury, 17 of
the 29 skiers who did not have surgery had a Lachman score of 0 to 1 and a
negative pivot shift test. Six of these patients were lost to follow-up, but 11
returned for a study-specific follow-up evaluation at more than 2 years
post-injury. These patients completed questionnaires that gauged how well the
knee was functioning and how their ski accident had occurred. They also
underwent Lachman and pivot shift tests and a KT-1000 test to measure motions
of the shin bone relative to the thigh bone.
Skiers described injuring their ACL
in tumbles where the ski had rotated too far. Physical exams revealed that 10
of the 11 patients still had Lachman scores of 0-1 and negative pivot shifts
tests, and only 1 patient's scores had deteriorated to a Lachman Grade 2+. None
of the patients, however, complained about knee instability. Eight had returned
to skiing without the use of a brace; 3 no longer skied. KT-1000 test results also
APTA member Greg Fives, PT, coauthored the article.
The federal government will be
running new health insurance marketplaces, also known as exchanges, in at
least 26 states, says an article by
Kaiser Health News. These states include the major population centers of
Texas, Florida, and Pennsylvania.
The Obama administration has given
"conditional approval" to 17 states and the District of Columbia to
run their own marketplaces. About 12 million people are expected to buy
coverage through the Internet sites next year, with the number increasing to 29
million by 2021, according to consulting firm PriceWaterHouseCoopers.
For consumers, it should make little
difference whether the new Internet sites are run from state capitals or
Washington, DC. But federal regulators hoped states would shoulder some of the
work and that stakeholder groups such as hospitals and insurers wanted states
to help, too. The exchanges become effective October 1.
Governors from Arkansas,
Delaware, Illinois, Iowa, Michigan, New Hampshire, and West Virginia have
sought approval for the third option— a partnership with the federal
government. Three of those states—Arkansas, Delaware, and Illinois—have
received conditional approval, says the article.
In a partnership, states would
approve which plans can participate on the marketplace and handle consumer
assistance duties, such as setting up call centers to handle inquiries. The
federal government would handle the more complex duties of running the website,
marketing the site, and determining the eligibility of millions
of people for government subsidies that will make prices more affordable.